Member Services Representative I - Bilingual Cantonese / Job Req 788843328

Principal Responsibilities

• Serve as the primary contact for members, providers and others for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns.
• Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination.
• Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so.
• May include assisting members in person.
• Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately.
• De-escalate situations involving dissatisfied customers, offering patient assistance and support.
• Accurately document all contacts per department standards/guidelines in the Customer Relationship Management (CRM) system.
• Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt).
• Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
• Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, and choosing a quality care provider.
• Intercede with care providers (doctor’s offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed.
• Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self-service tools that are available.
• Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow-up.
• Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues.
• Provide education and status on previously submitted pre-authorizations or pre-determination requests for both medical and pharmaceutical benefits.
• Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance.
• Always maintain a professional level of service to members.
• Always maintain confidentiality of information.
• Consistently support the Alliance’s approach to Service Excellence by adhering to established department and company standards for all work-related functions.
• Interact positively with all Alliance Departments.

Essential Functions of the Job

• Contacts: Receive, manage, and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules.
• Describe the types of services the Alliance offers to the Member within the managed care system.
• Provide clarification about issues regarding patient and physician rights and how the plan operates.
• Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed.
• Member communications: Create and/or mail appropriate member materials and communications as needed.
• Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.

Minimum Qualifications

• Bachelor’s degree or equivalent experience preferred.
• High school diploma, GED required.
• The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Vietnamese/English, Tagalog/English are required as designated.
• A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher.
• Minimum one year of direct customer service experience. Call center experience and managed care experience a plus.
• Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs.
• Demonstrated knowledge expert of AAH Member Services policies and procedures.
• Consistent record of meeting, maintaining, or exceeding monthly Departmental performance metrics.
• Consistent track record of documenting Service Requests accurately and clearly and monitoring open Service Requests to ensure responses and closure.
• Consistent record of high quality of work as demonstrated through call and documentation auditing, appropriate Call Disposition coding, as well as an overall acceptable monthly Member Satisfaction Survey result as assessed by Member Services Quality Specialist, MS Trainer and Member Services Supervisor.
• Demonstrated proficiency in current Customer Relationship Management (CRM) tool, phone system software Quality Management Solution, Pharmacy Benefits Management applications (PBM), Interpreter vendor scheduling software, delegate portal solutions and the Alliance’s Member portal.
• Demonstrated ability to effectively handle the department’s key special projects: Member Portal Request Processing, Kaiser PTE Requests, PCP retroactive and same month requests.
• Demonstrated ability to help members face-to-face in the field and/or at the Alliance offices (walk-ins). Also highly skilled at handling issues related to member bills, transportation set-up and benefit coordination with providers and pharmacy needs.